C A S E R EP O R T
ISSN: 2384-3799 Int J Thyroidol 2015 November 8(2): 187-189 http://dx.doi.org/10.11106/ijt.2015.8.2.187
Life-Threatening Upper Airway Obstruction Caused by Delayed Hematoma Occurring 8 Days Post-Thyroidectomy Kyeung A Ryu, Sung Tae Seo, Ki-Sang Rha and Bon Seok Koo Department of Otolaryngology-Head and Neck Surgery, Cancer Research Institute, Research Institute for Medical Sciences, Chungnam National University College of Medicine, Daejeon, Korea Due to modern methods, thyroid surgery is generally considered quite safe. However, post-thyroidectomy hematomas, although rare, can be life-threatening and unpredictable complications of thyroid surgery. Most postthyroidectomy hematomas occur within 24 hours of surgery, with delayed hematomas occurring after one post-operative week being exceedingly rare. Herein, we report a case of delayed post-thyroidectomy hematoma with respiratory distress occurring on the eighth post-operative day in a patient who was not taking anticoagulants and had no hematologic diseases. Although most bleeding occurs within 24 hours, caution should be used even in such patients who are considered low-risk. Key Words: Thyroidectomy, Hematoma, Postoperative complication
layed hematomas forming in the first post-operative
Introduction
week are exceedingly rare. We report a rare case of delayed post-thyroidectomy hematoma with respira-
Better preoperative preparation and proper surgical
tory distress occurring on the eighth postoperative day
techniques have decreased the rate of complications
in a patient who was not on anticoagulants and had
to less than 2-3% in thyroid surgery. The most dis-
no hematologic disease.
turbing complications of thyroid surgery include recurrent laryngeal nerve injury and permanent hypo-
Case Report
parathyroidism. Post-thyroidectomy hematomas, although rare, are potentially life-threatening and un-
A 52-year-old female presented to our department
predictable complications of thyroid surgery reported
for surgical treatment of thyroid cancer. She had no
at an incidence of 0.1-1.1%.
1)
notable medical history and her coagulation tests were
Relatively few studies have focused on prevention
normal. On surgery, the vessels were ligated by
of and risk factors for postoperative hemorrhage and
Harmonic scalpel. The specimen size was 4×2×1.5
hematoma after thyroidectomy. Most authors are un-
cm to right lobe, 4.5×1.5×1.5 cm to left lobe, 2.5×1
able to definitively identify perioperative risk factors for
cm to isthmus. Surgical drain was not inserted be-
2-4)
Most post-thyroi-
cause the blood loss was not significant and hemo-
dectomy hematomas occur within 24 hours and de-
stasis was well achieved by absorbable hemostat. The
the development of hematoma.
Received January 5, 2015 / Revised February 10, 2015 / Accepted February 16, 2015 Correspondence: Bon Seok Koo, MD, PhD, Department of Otolaryngology-Head & Neck Surgery, Chungnam National University College of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon 301-721, Korea Tel: 82-42-280-7695, Fax: 82-42-253-4059, E-mail:
[email protected] Copyright ⓒ 2015, the Korean Thyroid Association. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
187
Kyeung A Ryu, et al
duration of the surgery was about 60 min. Postoperative vocal cord movements were normal and there was no laryngeal edema. The incision appeared to be
rhage. After 5 days, the patient was discharged with no wound swelling.
healing well with no swelling 3 days post-operatively, so the patient was discharged.
Discussion
On the eighth postoperative day, the patient was rushed to the emergency room with a rapidly pro-
Hematoma following thyroid surgery is a rare but
gressive anterior neck swelling and acute respiratory
potentially life-threatening complication, with a re-
distress. Her respiratory rate was 30 breaths/min and
ported rate of 0.1% to 4.7%.5) It is generally difficult to
the SpO 2 was 59%. The patient was intubated then
predict which patients are at risk for developing hem-
a neck angio CT scan was conducted, which re-
atoma after thyroid surgery.6,7) Post-thyroidectomy
vealed a hematoma in the thyroidectomy bed and
hematoma may have a multifactorial etiopathogenesis,
edematous changes in the retrovisceral space and
including slipping of ligatures on major vessels, re-
upper mediastinum (Fig. 1). Her coagulation tests were
opening of cauterized veins, increased blood pressure
normal.
during recover. Coughing, the Valsalva maneuver,
Bedside decompression was performed in emergency room and revealed a deep hematoma. After
retching or vomiting can also increase venous pressure.
1-4)
hematoma removal in the thyroidectomy bed, the
While drains have long been used empirically in
bleeding focus was identified just above the cricoid
thyroid surgery, there are now many studies, including
cartilage as the cricothyroid artery, a branch of the
those of a randomized prospective nature, which fail
superior thyroid artery. The artery was electrocau-
to demonstrate benefits in preventing the formation of
terized and hemostasis was achieved. The patient
postoperative hematoma.8-11) Based on this, it would
stated that the anterior neck hematoma occurred
appear that drains do not have to be used as a pre-
acutely over several minutes without vigorous cough-
ventative measure.
ing or sneezing or other obvious reason for hemor-
Most post-thyroidectomy hematomas occur within 24 hours and in most cases, bleeding is likely due to post-surgical hypertension. Thus, very close monitoring of blood pressure during the first 24 hours after surgery and prompt appropriate treatment of any signs of hypertension is recommended. A study by Promberger et al.12) found that 80.6% of postoperative bleeds became symptomatic within 6 hours and 88.0% within 12 hours after the operation; only 10 (0.03%) patients demonstrated signs of bleeding after 24 hours. The occurrence of post-surgical complications has also been associated with anticoagulant agents or hematologic diseases such as von Willebrand disease, hemophilia and chronic renal failure.2) Two cases of very delayed bleeding occurring on the 13th postoperative day in patients who were taking anticoagulants have been reported.3) Our case is
Fig. 1. Neck angio-computed tomography (CT) scan of our patient. It showed a low-attenuating lesion with partial rim enhancement, suggesting a hematoma in the thyroidectomy bed.
highly unusual because our patient was not taking anticoagulants and the hematoma was markedly delayed until 8 days post-thyroidectomy. However, we Vol. 8, No. 2, 2015
188
Hematoma after Thyroid Surgery
suppose that the blood clot sealing the partially dam-
lic of Korea (0720560).
aged cricothyroid artery during surgery melted and some acute cause of increased blood pressure might
References
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7)
We experienced a highly unusual case of acute post-thyroidectomy hematoma that caused life-threatening upper airway obstruction on the eighth postoperative day without hematologic diseases, anticoagulant medications, or other predisposing factors for acute hemorrhage. Although most bleeding occurs within 24 hours after thyroidectomy, caution should be used, even in patients considered to be low risk.
Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (No. 2012R1A1A2005393, 2013R1A2A2A01015281), and a grant from the National R&D program for Cancer Control, Ministry for Health, Welfare, and Family Affairs, Repub-
189 Int J Thyroidol
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